A number of things quickly become evident when you work with clients who have addictive disorders.
- First, you are confronted with the profoundly impaired self-regulatory processes which are a result of autonomic nervous system dysregulation.
- Secondly, you are faced with the fact that there is a very high prevalence of developmental trauma manifested by these clients. Finally, there is a very high rate of relapse that is clearly related to the above two issues.
Substance use disorders and trauma, particularly developmental trauma, coexist in such prevalence that researchers consider the disorders to be “functionally linked.” That functional linkage is driven primarily by common brain mechanisms that play a central role in profound autonomic system dysregulation, and are highly sensitized to respond intensely to stress and psychoactive drugs. Ouimette et al, in summarizing the related research, stated:
By the time of treatment entry, the symptoms of substance use disorders and PTSD are…functionally linked…each disorder ultimately exacerbates the other…in the context of substance abuse treatment, PTSD treatment is expected to play a crucial role in maintenance of remission…the total number of PTSD counseling sessions…emerged as the single most significant predictor of remission [in a substance use disorder treatment group of clients]…
Teicher has written about the lifelong impact of early life developmental trauma, defined as chronic childhood abuse, neglect, or humiliation. He states that one is left with:
…physiological dysregulation leading to dramatic shifts between extreme states of hyper and hypo arousal, deficits in interpersonal relatedness, affect regulation, distress tolerance, ability to distinguish between internal and external reality, mindful awareness, ability to self sooth, tolerance of aloneness, regulation of self-hatred, shame and guilt, impulse control, ability to reflect rather than react reflexively, ability to mentalize (imagine how others might think or feel, and that such thoughs and feelings may be different form one’s own..
Schore also summarized the long term effects of early life attachment related developmental trauma as:
…enduring developmental impairment in critical dysfunctions of right brain…when stressed, show severe deficits in preattentive reception and expression of facially expressed emotion, the processing of somatic information, the social environment, the communication of emotional states, the maintaining of interactions with the social environment, the use of higher order defenses, the capacity to access an empathetic stance and reflective function, the psychobiological ability to self-regulate, either by autoregulation or interactive regulation, and thereby recover from stressful affective states…these dysfunctions represent pathological alterations of implicit, unconscious mechanisms…
When a client has a history of developmental trauma, which obviously predates psychoactive substance use, the substance use is a solution to the above deficits, a solution that becomes its own problem and ultimately worsens the original dysfunctions. If the individual tries to get clean and sober, all of the trauma related material begins to rapidly emerge. This usually triggers the person back into active substance dependence. To succeed, these clients, first and foremost, need an effective way of addressing the intense autonomic dysregulation that drives the symptoms. Pharmacological interventions may lessen symptoms in the short term, but since drugs cannot attenuate the underlying dysregulation, and in fact, over time, will often contribute to a further worsening of the client’s condition. These clients are significantly compromised neurologically, and manifest so many symptoms, that prescribed drugs just further complicate treatment, with the prescriber often quickly adding multiple drugs (and diagnoses), often to counteract the side effects of the initial prescribed drugs.
Various psychotherapeutic approaches are also limited in their usefulness in providing physiological stabilization, primarily due to the fact that cognitive and affective capacities are significantly impaired. In my own search for ways to address this profound autonomic dysregulation, I have pursued training in clinical hypnosis, cognitive behavioral therapy, psychodynamic therapy, EMDR, sensory motor psychotherapy, and numerous other approaches, all with limited results. Due to the intense bottom up hijacking by overresponsive, sensitized brain stem and limbic mediated brain areas that override top down, frontal and prefrontal executive regulating capacities, most traditional therapies are limited when used for stabilization, the first task in treating these clients. Right brain, bottom up emotional processes dominate and overwhelm these clients, in most cases, quickly precipitating relapse. Those that do not relapse, often are left to resort to self destructive defensive behaviors, substitute compulsions, or the numbness that often comes with certain prescribed medications.
When first introduced to neurofeedback I was excited about the possibility of directly impacting the brain in ways that would stabilize a client’s dysregulated autonomic system. I began to explore various approaches, power training, alpha-theta, zscore, HEG, etc. All these approaches proved somewhat helpful with this clinical population, however, ISF Neurofeedback training, from the moment I began using it, has consistently produced the most significant physiological shifts in my clients. As their autonomic system becomes more regulated, as evidenced by decreasing sleep problems, nightmares, flashbacks, drug cravings, and responses to trauma related triggers, they are more able to exert top down control of affective and emotional responses. This leads to an ability to respond reflectively rather than reflexively, which is a clear indication of both the quieting of the autonomic nervous system, and the improvement of the brain’s frontal executive function capacities. These clients become much more available and able to participate in psychotherapy. ISF has become the primary modality I use to bring about stabilization in work with a client population that is plagued by dramatic autonomic dysregulation.
I am first, and primarily a psychotherapist. My point in doing this posting is to speak to other therapist working with trauma and/or substance use disorders. ISF, no doubt, has improved my clinical effectiveness. For a while it consumed all of my clinical time, to the point where I was doing very little psychotherapy. Numerous colleagues began sending clients for the stabilization I was providing with ISF, and the neurofeedback practice swamped me. I have since brought on some staff to help with the neurofeedback, so that I can maintain a balance between continuing to explore the capacities of neurofeedback, and in particular ISF, and psychotherapy. ISF neurofeedback and psychotherapy are not distinct and exclusive of one another, since ISF, more than my experience of other forms of neurofeedback, demands clinical skills. Clients usually have physiological and emotional responses from the beginning of their treatment, necessitating interpretation and interactive framing for the client. These reactions are also critical to identifying treatment decisions from session to session. As a result, becoming an ISF practitioner has been a comfortable fit for me as a therapist. It has also become the single most important tool I use for the majority of my clients.
Ouimette, P. and Brown, P. Trauma and Substance Abuse
Schore, A. Affect Regulation and the Repair of Self
Teicher, M.H. Sticks and Stones and Hurtful Words: Relative effects of various forms of childhood maltreatment.